Pregnancy-Related Mortality in California Due to Obstetric Hemorrhage

Despite prevention efforts over the last decade, obstetric hemorrhage remains a leading cause of pregnancy-related mortality in California and was found to be highly preventable (63%) in an analysis of 49 deaths.

Hemorrhage is largely a clinical issue, but public health can promote awareness of anemia and other patient risk factors to ensure that the birthing population goes to the appropriate level hospital that can care for them if they are at greater risk (e.g., prior Cesarean delivery, 35 years or more, more than 2 prior deliveries, etc.).

This article, authored by the California Pregnancy-Associated Mortality Review (CA-PAMR) and published in Obstetrics & Gynecology, explores underlying causes, contributing factors, and quality-improvement opportunities of pregnancy-related hemorrhage deaths—and identified discrimination based on language, race/ethnicity, socioeconomic status, or substance use disorder in almost a quarter of deaths.

CA-PAMR is a collaboration between the California Department of Public Health’s Maternal, Child and Adolescent Health Division, its contracting partners at Stanford University’s California Maternal Quality Care Collaborative (CMQCC) and the Public Health Institute (PHI), and its multidisciplinary expert committees.

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Objective

To identify underlying causes, contributing factors, and quality-improvement opportunities of pregnancy-related hemorrhage deaths.

Methods

The California Pregnancy-Associated Mortality Review examined pregnancy-related hemorrhage deaths in California that occurred in 2014–2018. Data were abstracted from multiple sources (vital records, hospital encounter data, medical records, and coroner or autopsy reports). A multidisciplinary expert panel reviewed all case summaries. Data from reviews were aggregated to determine underlying causes of death, preventability, contributing factors, and quality-improvement opportunities at the patient, clinician, facility, and system levels.

Results

During the study period, there were 2,409,732 live births and 49 pregnancy-related hemorrhage deaths. Placenta accreta spectrum accounted for 16 (32.7%) of deaths; intra-abdominal bleeding and uterine atony each accounted for 10 deaths (20.4%). Compared with the California birth population, a significantly higher proportion of women who died were born in China (14.3% vs 3.9%); were 35 years of age or older (49.0% vs 21.9%); had two or more prior births (57.4% vs 29.1%); had cesarean deliveries (74.4% vs 31.8%); or delivered at hospitals with fewer than 1,200 births per year (33.3% vs 12.2%) (all P<.05). The committee determined that 63.3% of all hemorrhage deaths were highly preventable with substantial variation by cause. Clinician-, facility-, and system-level contributing factors were noted in 88.9% of cases and included delayed response or escalation (77.8%), delayed recognition (72.2%), and insufficient quantities of blood products used (52.8%). Corresponding quality-improvement opportunities included timely hemorrhage risk assessment; increased vigilance for identifying signs and symptoms of hemorrhage; escalation of care and aggressive management; preparation for hemorrhage complications and ongoing training for all hospitals, particularly low-resource facilities; and adherence to severe hemorrhage protocols.

Conclusion

Obstetric hemorrhage remains a leading cause of pregnancy-related mortality and has multiple causes with various levels of preventability. Optimizing system-based approaches for hemorrhage preparedness, detection, and clinical management is critical to reduce preventable deaths from hemorrhage, especially among patients who do not respond to first-line treatment.